Dance Registration 2009/2010
Fill out and return with the
non-refundable registration fee of $20 to:
Debbie Kogut
9 Rice street
Uxbridge Ma 01569
Student Name__________________________Age___________
Parent(s)____________________________________________
Address_____________________________________________
Home #______________Cell #____________work #_________
EMail Address________________________________________
Class interested in____________________________________
Registration Fee Pd: check #_________Date pd____________
Additional Notes:______________________________________
